PERIO Week 3

Classification of Periodontal and Peri-Implant Diseases

Introduction to the Periodontal Classification System

  • The periodontal classification system is essential for
    • Communicating clinical findings accurately to dental healthcare providers.
    • Formulating a diagnosis and creating individualized treatment plans.
    • Predicting treatment outcomes (prognosis).
    • Submitting information to dental insurance providers/carriers.

Historical Overview of Classification

  • 1999 Classification System
  • 2017 AAP/EFP Classification of Periodontal and Peri-Implant Diseases and Conditions
    • Introduced by the American Academy of Periodontology (AAP) and European Federation of Periodontology (EFP).
    • Developed during the “World Workshop.”
    • Last update was in 1999; the 2017 revision accounts for scientific advances and standardizes definitions.

Classification of Periodontal and Peri-Implant Diseases and Conditions

2017 Classification Overview

  • Divided into:
    • Periodontal Diseases and Conditions
    • Peri-Implant Diseases and Conditions
Periodontal Diseases and Conditions
  • Periodontal Health, Gingival Diseases, and Conditions
    • Refer to consensus reports such as those by Chapple, Mealey et al. (2018) and Trombelli et al. (2018).
  • Periodontitis
    • Refer to consensus reports from Papapanou, Sanz et al. (2018), Jepsen, Caton et al. (2018), and Tonetti, Greenwell, Kornman (2018).
  • Other Conditions Affecting the Periodontium
    • Reflections on cases by Jepsen, Caton et al. (2018) and Papapanou, Sanz et al. (2018).
Peri-Implant Diseases and Conditions
  • Key Categories:
    • Peri-Implant Health
    • Peri-Implant Mucositis
    • Peri-Implantitis
    • Peri-Implant Soft and Hard Tissue Deficiencies

Periodontal Health and Gingival Diseases/Conditions

  • Refer to Chapter 5 @TYLERPERIO for in-depth analysis.
Definition of Periodontal Health
  • Described as a state free from inflammatory periodontal disease that allows for normal function and avoidance of mental or physical consequences due to current or past diseases.
Characteristics of Periodontal Health
  • Absence of the following indicators:
    • 1) Bleeding on probing; essential for recognizing healthy gums.
    • 2) Erythema; absence of redness in the gingiva.
    • 3) Edema; no swelling of the tissues.
    • 4) Attachment loss; no loss of connective tissue attachment to the teeth.
    • 5) Alveolar bone loss; maintaining bone levels unaffected by disease.
Tissue Color in Health
  • Normal color is uniform and pink.
  • Physiological pigmentation can occur in darker complexions due to melanin production.
  • Distinction is made between coral pink gingiva and dark red alveolar mucosa.
Tissue Contour (Size and Shape) in Health
  • The gingival margin should tightly encircle the cervical margin of the tooth.
  • Normal appearance is smoothly scalloped and tapered gingival margins with pointed triangular papillae.
Tissue Consistency and Texture in Health
  • Attached gingiva should be keratinized and firmly bound to underlying structures.
  • Healthy tissue upon probing should feel firm and resilient without bleeding.
  • Stippling (dimpled appearance) may be present in healthy gingiva.
Position of Gingival Margin
  • The margin should ideally coincide with the level of the cementoenamel junction (CEJ) or be slightly coronal to it.

Differentiating Intact vs. Reduced Periodontium

  • Intact Periodontium:
    • No loss of periodontal tissue (connective tissue or bone).
  • Reduced Periodontium:
    • Indicates past loss of periodontal tissue that is currently stable, such as in patients recovering from periodontitis or other factors like orthodontic therapy.

Clinical Gingival Health Assessments

  • Distinctions are made in assessing gingival health on both intact and reduced periodontium.
Dental Biofilm-Induced Gingivitis
  • The most prevalent form of periodontal disease.
  • Management of gingivitis is crucial to prevent periodontitis.
  • Inflammation arises due to plaque biofilm accumulation beneath the gingival margin.
  • Common Features:
    • Red and swollen tissue that bleeds easily.
    • Less intense inflammation observed in children compared to young adults due to different immune responses.
Gingivitis Features
  • Tissue appearances include:
    • Bulbous: enlarged and protruding from the interproximal space.
    • Cratered: having a scooped-out, concave appearance.
    • Blunted: flat and not filling the interproximal spaces.
Tissue Consistency and Surface Texture
  • Affected gingiva loses the firm texture,
  • Tissue may become spongy, deflecting easily under pressure.
  • The presence of stippling may be lost,
  • The gingival margin may appear more coronally positioned due to swelling.
Bleeding on Probing
  • Bleeding occurs with gentle probing before redness is visible.
  • The tissue lining of the sulcus can become ulcerated with engorged blood vessels.
  • Heavier bleeding correlates with increased inflammation.
Extent and Distribution of Inflammation
  • Classification based on:
    • Extent of inflammation:
    • Gingival health: less than 10%
    • Localized gingivitis: 10-30%
    • Generalized gingivitis: >30%
    • Distribution of inflammation:
    • Papillary: inflammation confined to interdental papilla (papillary gingivitis).
    • Marginal: inflammation of the gingival margin and papilla (marginal gingivitis).
    • Diffuse: includes inflammation of the entire gingival area (diffuse gingivitis).

Management of Dental Biofilm-Induced Gingivitis on Various Periodontiums

  • On intact periodontium, treatment focuses on biofilm management.
  • On reduced periodontium, there's a higher risk of relapse, especially in patients with history of treated periodontitis.

Systemic Conditions as Modifying Factors

Factors Influencing Gingival Inflammation
  • Sex and Steroid Hormones:
    • Changes in hormone levels during puberty, menstrual cycle, and pregnancy can lead to increased inflammation.
  • Pregnancy-Associated Pyogenic Granuloma:
    • A benign growth that may appear during pregnancy due to inflammation triggered by plaque.
  • Hyperglycemia:
    • Elevated glucose levels affect gingival inflammation, more crucial than the amount of plaque.
  • Leukemia:
    • Associated with significant gingival tissue enlargement and bleeding, often without the presence of plaque biofilm.
  • Smoking:
    • Decreases clinical signs of inflammation; promotes gingival fibrosis.
  • Malnutrition:
    • Vitamin C deficiency is critical as it weakens the periodontium's structural integrity.
  • Oral Factors Enhancing Biofilm Accumulation:
    • Such as poor restoration margins and decreased salivary flow.
Drug-Induced Gingival Enlargements
  • Certain medications can lead to the enlargement of gingival tissues,
    • Types of Medication:
    1. Anticonvulsants (e.g. phenytoin)
    2. Immunosuppressants (e.g. cyclosporine)
    3. Calcium channel blockers (e.g. amlodipine, nifedipine, verapamil)
  • Enlargement typically presents within three months of commencement of the drug.
  • Characterized by a painless area starting from the papilla and extending to the marginal gingiva.

Non-Dental Biofilm-Induced Gingival Diseases and Conditions

Genetic/Developmental Abnormalities
  • Hereditary Gingival Fibromatosis:
    • A rare condition leading to progressive gingival enlargement.
Infections of Bacterial Origin
  • Manifest as ulcerations or patches resulting from specific bacteria not present in standard plaque biofilms.
Inflammatory and Immune Conditions
  • Hypersensitivity Reactions:
    • Reactions to flavoring agents causing widespread gingivitis.
    • Suggested treatments include changing oral hygiene products.
  • Plasma Cell Gingivitis;
  • Erythema Multiforme: characterized by red patches and/or ulcerations.
  • Oral Lichen Planus:
    • A chronic condition requiring monitoring, associated with higher cancer risk.
    • Characterized by lacy white patches and sometimes painful sores in the oral cavity.